Connecticut Release Of Information Form

Transcript

RELEASE OF INFORMATION Patient Full Name: __________________________________ Previous Names (if applicable) _____________________ Patient Address: _______________________________________________ Date of Birth: ________________________ City: ______________________ State: ________ Zip Code: ___________ Phone #: ___________________________ I authorize any member of the medical staff of Connecticut Children’s Medical Center and/or Connecticut Children’s Specialty Group or any of its employees or representatives to use and/or disclose my protected health information (PHI) as provided below. I understand that I may revoke this Authorization, except to the extent that the entity has already taken action in reliance on this Authorization. The written revocation letter needs to be sent to the Health Information Management (HIM) Department of Connecticut Children’s Medical Center. The provision of treatment will not be conditioned on the completion of this Authorization. I understand that once the PHI listed below is used or disclosed as set forth in this Authorization, such information is subject to re-disclosure and may no longer be protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that a fee may be charged for this service and that prepayment may be required. INFORMATION TO BE USED BY/DISCLOSED FROM: (Check the appropriate box(es))  Connecticut Children’s Medical Center Connecticut Children’s Specialty Group  Other INFORMATION TO BE USED BY/DISCLOSED TO: Provider Name/ Organization: _______________________________________________________________ Address:________________________________________________________________________________ City, State, Zip:___________________________________________________________________________ Phone #:_______________________________ Fax # _______________________________ PURPOSE OF USE/DISCLOSURE:  At request of patient  Other ______________________________________________________________________ INFORMATION TO BE USED/DISCLOSED:  Complete Medical Record Date(s) of Service: ________________________________________________  Inpatient Medical Record Date(s) of Service: ________________________________________________  Outpatient Medical Record Department(s): _________________________Date(s) of Service: _________________  Other: __________________________________ Date(s) of Service: ______________________________________ I understand that state law prohibits the use and/or disclosure of the PHI listed below unless specifically authorized by me. I understand that such information will not be used or disclosed unless I indicate by initialing below. Mental Health / Psychiatric: (initials) __________________ HIV Tests & Related Information: (initials) __________________ Alcohol and/or Substance Abuse: (initials) __________________ EXPIRATION DATE: Unless I revoke this Authorization or provide a different expiration date below, this Authorization will expire twelve (12) months from the date of execution.  Other Expiration Date: _______________________________________________ SIGNATURE: If the patient is unable to sign, please indicate the authority of the person who is signing for the patient. _______________ Date ________________________________ Signature of patient/representative ____________________ Print name ___________________ Relationship to patient